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Report an Auto Claim
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Auto Loss Claim
General claim form to report an auto loss
Date of Loss
*
Date Format: MM slash DD slash YYYY
Entity Name:
*
Group or JPA Coverage Name:
Name
*
First
Last
Phone
*
Email
*
Vehicle Make (e.g. Ford, Chevrolet):
*
Vehicle Model (e.g. Taurus, F150, Caprice):
*
Vehicle Engine Size (e.g. v6, v8, 3.0 liter):
Vehicle Year:
*
Odometer Mileage Amount:
Vehicle Identification Number (VIN)t:
*
Department (associated with vehicle, e.g. Police, Public Works)
*
Check all equipment and feature options of vehicle
Automatic Transmission
Manual Transmission
2 Door
4 Door
Anti-Lock Brake System (ABS)
Air Conditioning
CD Stereo
Tilt Wheel
Power Locks
Power Steering
Power Windows
Power Seats
Air Bags
Cruise Control
4-Wheel Drive
Premium Wheels
Luggage Rack
Other
Location of Loss or Accident:
*
Brief Description of Accident or Loss Damages:
*
File Upload
Attach any accident investigation documents, police reports, or other supporting information.
Drop files here or
File Upload
Attach copies of two independent estimates of cost
Drop files here or
Name of Other Person or Party Involved (if applicable)
First
Last
Phone of Other Person or Party Involved
Address of Other Person or Party Involved
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insurance Carrier of Other Person or Party
Policy or Member Number:
Phone of Insurance Carrier
